CRS Legislative Updates

Out of Network/ Balance Billing Legislation Sent to Governor

AB 72 (Bonta) is the new vehicle which would ban balance billing and create a process for determining interim payment rates for out of network physicians who provide services in contracted hospitals and other facilities. A small workgroup of Assembly Democratic and Republican members have been developing a compromise solution involving all stakeholders including physicians.

AB 72 as amended passed both the Senate and Assembly this week during the end of the Legislative Session with near unanimous votes in both Houses. The interim payment amount for an out of network physician is now the greater of 125% of Medicare or the average contracted rate of the plan. The bill continues to contain an IDRP process whereby a physician/group could appeal for a higher level of payment above the interim payment amount. The bill does include some provisions to address the network adequacy requirements for plans that we believe contribute in large part to the out of network billing issue. The law will not take effect until July 1, 2017 for any policy that is issued or renewed on or after that date. Both DMHC and DOI have to establish an IDRP process and there will be some stakeholder engagement on issues prior to that date. The CRS had moved to a neutral position on AB 72 and the CMA also changed their position to neutral prior to the floor votes. The Governor has 30 days to take action on AB 72 but we assume he will sign the bill. Once the law is signed we will provide more detail on the various provisions.

Insurance/ Plan Payment for Digital Breast Tomosynthesis

The CRS continues to push for coverage of DBT by private insurers. Existing law requires insurers and plans to cover all screening and diagnostic mammography services ordered by a physician but almost all are denying coverage for DBT claiming it is investigational. Though our sponsored bill AB 2764 (Bonilla) stalled in the Assembly fiscal committee in recent weeks the following has occurred;

CRS has sent letters to both the Department of Managed Health Care and the Insurance Commissioner requesting that they require plans and insurers to cover DBT without patient cost sharing based upon federal law and the ACA.

CRS representatives met with the medical directors and contract staff for both Blue Shield and Anthem Blue Cross to urge them to alter their medical policies and cover DBT. We met with Anthem at the offices of DMHC and they indicated their concern with the high number of IMR requests by patients.

DMHC website shows 376 IMR decisions involving DBT and 93% of those decisions overturn the plan denials. DMHC stated that another 400 IMRs were in the pipeline for review.

CIGNA announced that effective Aug. 23, 2016 that they would cover and reimburse for DBT.

We know that some groups are encouraging their patients to utilize the DMHC IMR process to appeal the denial of coverage. We suggest that all radiology groups who provide DBT continue to help their patients. DMHC is aware of the issue and recommends that any patient who is denied coverage of DBT by their plan can submit a simple one-page form requesting IMR review.

Since the denial is made by the plan on the basis that the procedure is "investigational" the patient can use the IMR process without having to appeal internally to the plan. Given the current 90% or greater denial rate for DBT by health plans as "investigational or experimental" we have the opportunity and should empower our patients to go straight to the Independent Medical Review process of the DMHC to obtain satisfaction at two levels. First the denial will be overturned and second the cost of the entire process of review goes on the health plan. Some radiology providers are seeing plans reverse course and pay for the service once an IMR is filed.

The IMR process can bring the plans to awareness quickly if thousands arrive. Each center should make a vow to Inform, Sign, Retain, and Send in a minimum of 100 IMRs each week.

The process of submitting on behalf of patients their IMRs for DBT. Please proceed with:

Informing patients at the Time of Service why we are standing with them on the fight against breast cancer by having them sign at the time of service, their authorization for IMR on the full expectation of a coming denial for DBT.

Obtain signatures on the IMR form (DMHC website) from patient signature line and "authorization to assist" signature line. Two signatures here.

Retain their form in center on their behalf awaiting notification of denial of payment by their health plan

Submit IMR to the DMHC upon receipt of denial on behalf of the patient

The four step process for each center would then be: Inform, Obtain signatures, Retain, Submit upon notification of denial. We have included a copy of an explanatory form being used by one radiology group to educate their patients. It might be useful as a template for what DBT providers can use with their patients.

Since the Department of Insurance (DOI) also regulates some heath care insurance policies they may have jurisdiction. DOI mostly regulates PPO products and on their website they also have an electronic means for either a patient for file an IMR or a provider to file a complaint over a lack of coverage. Please go to www.insurance.ca.gov and click the link for consumers. The insured's insurance ID card may indicate the type of insurance or the patient can ask their insurer who has jurisdiction over the policy.

Digital Breast Tomo Coverage

Though CRS sponsored legislation, AB 2764 (Bonilla), was held in the Assembly Appropriations Committee we continue to work to get the major payers to cover DBT. Many groups have helped their patients file Independent Medical Review (IMR) requests with the Department of Managed Health Care if their plan denies payment for DBT claiming it is investigational/ experimental. The DMHC website shows some 351 IMRs reviewed for DBT with over 90 % of the decisions reversing the plan denial of coverage. Please continue to encourage or assist your patients file IMRs if you provide DBT.

The CRS continues to do outreach to major plans to encourage that they reconsider any policies that deny coverage for DBT. We recently met with Blue Shield policy managers and will be meeting with Anthem Blue Cross this month. Our thanks to Dr. James Schlund and his colleagues at the Chico Breast Center for hosting the Blue Shield meeting and representatives of Hologic who have provided key information on studies and changes being made to cover DBT by other plans around the country.

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